Healthcare costs currently represent approximately 13 percent of the United States Gross National Product, and they continue to rise at a rapid pace. Managed healthcare systems are faced with the challenges of controlling the soaring costs of healthcare delivery and properly allocating healthcare resources. Both of these tasks are facilitated by a tool that explains prior healthcare utilization and provides an accurate estimate of future healthcare costs and utilization by the various members of the plan.
When a member of a healthcare plan receives care from healthcare providers, information regarding the care received is provided to plan administrators in documents commonly referred to as claims. Predominantly, this information is provided in the following three types of claims: physician claims, hospital claims, and pharmacy claims. These claims are the documents that are submitted to the healthcare plan by physicians, hospitals, or pharmacies to receive reimbursement for care provided to the plan member. These documents generally contain coded data that provides information regarding the care received by the plan member. These claims are processed by the healthcare plan and, where appropriate, payment is transmitted to the healthcare provider. For purposes of this specification, the phrase “physician claim” is used to refer to any professional service claim (e.g., optometrist) submitted to a health plan, typically on a HCFA 1500 form or its equivalent, and the phrase “hospital claim” is used to refer to any facility claim (e.g., outpatient surgery center) submitted to a health plan, typically on a UB92 form or its equivalent.
The healthcare utilization modeling methods of the prior art sacrifice reliability because they use only a portion of the readily available information, use portions of the information that do not reliably model utilization, or combine information in an unreliable way. There is a need in the art for a system and method for more reliably modeling healthcare utilization based on the data readily available in claims submitted to a health plan by healthcare providers.
The following materials serve as background for the present application and provide further information on some of the classification systems discussed in this specification: Physician's Current Procedure Terminology CPT '94, published by the American Medical Association, Code it Right Techniques for Accurate Medical Coding, published by Medicode, Inc., HCPCS 1994 Medicare's National Level II Codes, published by Medicode, Inc., Med-Index ICD 9 CM Fourth Edition 1993, published by Med-Index, each of which is hereby incorporated by reference.